Anan Shtaya

Image guidance and improved accuracy of external ventricular drain tip position particularly in patients with small ventricles

OBJECTIVEExternal ventricular drain (EVD) insertion is one of the most common emergency neurosurgical procedures. EVDs are traditionally inserted freehand (FH) in an emergency setting, but often result in suboptimal positioning. Image-guided surgery (IGS) is selectively used to assist placement. However, the accuracy and practicality of IGS use is yet to be reported. In this study, the authors set out to assess if IGS is practical and improves the accuracy of EVD placement.METHODSCase notes and images obtained in patients who underwent frontal EVD placement were retrospectively reviewed. Ventriculomegaly was determined by the measurement of the Evans index. EVD location was classified as optimal (ipsilateral frontal horn) or suboptimal (any other location). Propensity score matching of the two groups (IGS vs FH) for the Evans index was performed. Data were analyzed for patient age, diagnosis, number of EVDs, and complications. Those without postoperative CT scans were excluded.RESULTSA total of 607 patients with 760 EVDs placed were identified; 331 met inclusion criteria. Of these, 287 were inserted FH, and 44 were placed with IGS; 60.6% of all unmatched FH EVDs were optimal compared with 75% of the IGS group (p = 0.067). The IGS group had a significantly smaller Evans index (p < 0.0001). Propensity score matching demonstrated improved optimal position in the IGS group when compared with the matched FH group (75% vs 43.2%, OR 4.6 [1.5-14.6]; p = 0.002). Patients with an Evans index of ≥ 0.36 derived less benefit (75% in IGS vs 66% in FH, p = 0.5), and those with an Evans index < 0.36 derived more benefit (75% in IGS vs 53% in FH, p = 0.024). The overall EVD complication rate was 36% in the FH group versus 18% in the IGS group (p = 0.056). Revision rates were higher in the FH group (p = 0.035), and the operative times were similar (p = 0.69). Long intracranial EVD catheters were associated with tip malposition irrespective of the group.CONCLUSIONSImage guidance is practical and improves the accuracy of EVD placement in patients with small ventricles; thus, it should be considered for these patients.

Choroid Plexus in the Central Canal of the Spinal Cord Causing Recurrent Syringomyelia

BACKGROUND Syringomyelia is a fluid-filled cavitation within the substance of the spinal cord. This condition usually follows a primary pathology that disrupts the normal cerebrospinal fluid circulation or disturbs the microcirculation and cytoarchitecture of the spinal cord parenchyma. However, an etiology of recurrent syringomyelia resulting from an ectopic choroid plexus (CP) has not been discussed. Ectopic CP rests may be found within the central nervous system. Although there has been a single report, describing ectopic intramedullary spinal cord CP, to our knowledge, extra-cranial nonmalignant CP in the central canal of the spinal cord has not been reported. CASE DESCRIPTION We report CP in the central canal of the spinal cord in a 23-year-old male patient who had developmental delay and diabetes mellitus type I who presented with dissociated sensory changes and muscle wastage predominantly on the right upper and lower limbs. Magnetic resonance imaging demonstrated a multiloculated spinal cord syringomyelia stretching from cervical (C3) to the conus medullaris causing recurrent neurologic deficits. A biopsy of the central canal spinal cord lesion revealed CP. Decompression and syringosubarachnoid shunt insertion stabilized the patients neurology. CONCLUSIONS Our illustrative case reveals the presence of CP in the central canal of the spinal cord that may suggest a role in the etiology of recurrent syringomyelia. Although management poses a challenge to neurosurgeons, prompt decompression and shunting of the syringomyelia remains a favorable approach with acceptable outcomes. Further investigation into the pathophysiology of central canal CP ectopic causing recurrent syringomyelia and its correlation with spinal cord development may help future treatments.

Ventral Lumbar Synovial Cyst Causing Cauda Equina Compression: Case Report and Literature Review

BACKGROUND Juxtafacet spinal cysts are cystic synovial lesions that often are indistinguishable clinically or radiologically and require histopathology analysis to confirm the diagnosis. Lumbar synovial cysts usually arising from the synovium of the facet joints. They have been described posterolaterally or rarely in the posterior midline. However, we describe the first synovial cyst ventral to the dural sac. CASE DESCRIPTION We report a lumbar 3-4 lesion causing cauda equina compression in a 57-year-old man who presented with a 3-month history of low back pain and bilateral sciatica, intermittent urinary incontinence, and erectile dysfunction. Preoperative magnetic resonance imaging suggested prolapsed disc, after decompression, histological analysis of the fragment confirmed a synovial cyst. CONCLUSIONS Hitherto synovial cysts have not been reported anterior to the dural sac. We describe a lumbar ventral cystic mass with cauda equina compression that mimicked a disc prolapse due to synovial metaplasia. The patient had urgent decompression with subsequent resolution of the symptoms.

A rare case of a calcified cephalhematoma mistaken as a skull fracture

A 2-month-old-boy presented to our emergency department with an apparent depressed area in the left parietal region. His mother informed the emergency department about ventouse and forceps-assisted delivery at 41 weeks’ gestation with unremarkable antenatal care. She noticed an initial soft swelling that was diagnosed at the time as a cephalhematoma and was conservatively treated. The swelling eventually decreased in size and hardened. There was no history of trauma; clinical examination was unremarkable apart from positional plagiocephaly and the presence of a depressed area in the left parietal region. Skull X-ray was inconclusive; ultrasound (Fig. 1A) suspected a skull fracture. Head computed tomography (Fig. 1CeF) revealed an outer surface of calcified cephalhematoma that collapsed inward, giving the appearance of a depressed parietal fracture. The natural course of cephalhematomas is gradual resorption; however, they may

Disco vertebral osteomyelitis causing intradural spinal abscess with cauda equina compression

Abstract Intradural extramedullary spinal infections causing cauda equina compression are uncommon. We report an Escherichia coli bacteraemia causing lumbar discitis and an intracanalicular collection compressing the cauda equina: initially thought to be an epidural empyema, however microsurgery revealed an intradural location. Decompression, drainage, antibiotics, and neuropathy treatment are essential management.

An incidental finding on computed tomography scan

A 10 year old girl was referred for a computed tomography (CT) scan of the head after having had intermittent headaches for two months following a head injury (fig 1⇓). On examination, she had bilateral papilloedema. The main finding on the CT scan was a left subacute subdural haematoma. What else is shown in the …